Participating, Non-Participating, and Opt-Out Medicare Providers

Overview

These notes cover the distinctions between participating, non-participating, and opt-out Medicare providers and how each impacts patient costs for services under Medicare Part B.

Types of Providers

1. Participating Providers

   • Accept Medicare and always take assignment.
   • Must submit a bill to Medicare, who then pays the provider directly.
   • Patients pay 20% coinsurance for services.
   • Certain providers must always take assignment if they accept Medicare (e.g., clinical social workers).

2. Non-Participating Providers

   • Accept Medicare but do not always take assignment.
   • Can charge up to 15% more than Medicare's approved amount (limiting charge).
   • Patients may be responsible for up to 35% of the approved amount (20% coinsurance + 15% limiting charge).
   • Limiting charge may be lower in some states (e.g., 5% in New York).
   • Providers should submit a bill to Medicare even if the full cost is paid upfront by the patient.
   • Limiting charge rules do not apply to Durable Medical Equipment (DME) suppliers.

3. Opt-Out Providers

   • Do not accept Medicare at all and have signed an agreement to be excluded from the program.
   • Can charge any amount for services but must provide a private contract explaining charges.
   • Medicare does not pay for services (except in emergencies), and patients are responsible for all costs.
   • Opt-out providers do not bill Medicare.

Billing and Payment

• Providers taking assignment should bill a Medicare Administrative Contractor (MAC) within one year.
• If the deadline is missed, the provider cannot bill Medicare but can still charge the patient a 20% coinsurance and any deductible.

Recommendations

• Ask your provider whether they are participating, non-participating, or opt-out.
• Use Medicare’s Physician Compare tool to check provider status.

Additional Information

• Related Topics

  • Part B Costs
  • Troubleshooting claim issues
  • Medicare Summary Notice (MSN)
  • Durable Medical Equipment (DME) supplier basics

• Resources

  • State Health Insurance Assistance Program

These points summarize the key distinctions and important considerations when dealing with different types of Medicare providers and understanding the resulting financial responsibilities.